RCMR_MT000001UV01 | This RMIM is used to derive Medical Records speciications. Derived from RMIM: RCMR_RM000030 and HMD: RCMR_HD000030UV01 | ||||||||
ClinicalDocument | |||||||||
classCode [1..1] (M) Act (CS) {CNE:DOCCLIN, default= "DOCCLIN"} | |||||||||
moodCode [1..1] (M) Act (CS) {CNE:EVN, fixed value= "EVN"} | |||||||||
id [1..1] Act (II) | |||||||||
code [1..1] Act (CE) {CWE:DocumentType} | |||||||||
text [0..1] Act (ED)Constraint: Message RCMR_MT000002 is to be used when including the document itself. RCMR_MT000001 sends document metatadata, but not the document, thus precludes ED.BIN from use. | |||||||||
statusCode [1..1] Act (CS) {CNE:ActStatus} | |||||||||
effectiveTime [1..1] Act (TS) | |||||||||
availabilityTime [0..1] Act (TS) | |||||||||
confidentialityCode [0..1] Act (CE) {CWE:x_BasicConfidentialityKind, default= "N"} | |||||||||
reasonCode [0..1] Act (CE) {CWE:ActReason} | |||||||||
languageCode [0..1] Act (CS) {CNE:HumanLanguage} | |||||||||
setId [0..1] ContextStructure (II) | |||||||||
versionNumber [0..1] ContextStructure (INT) | |||||||||
completionCode [0..1] Document (CE) {CWE:DocumentCompletion} | |||||||||
storageCode [0..1] Document (CE) {CWE:DocumentStorage} | |||||||||
copyTime [0..1] Document (TS) | |||||||||
subject [0..*] (Subject) | |||||||||
recordTarget [1..*] (RecordTarget) | |||||||||
responsibleParty [0..1] (ResponsibleParty) | |||||||||
author [1..*] (Author1) | |||||||||
dataEnterer [0..1] (DataEnterer) | |||||||||
custodian [1..1] (Custodian) | |||||||||
informationRecipient [0..*] (InformationRecipient) | |||||||||
legalAuthenticator [0..1] (LegalAuthenticator) | |||||||||
authenticator [0..*] (Authenticator) | |||||||||
participant [0..*] (Participant) | |||||||||
inFulfillmentOf [0..*] (InFulfillmentOf) | |||||||||
documentationOf [0..*] (DocumentationOf) | |||||||||
relatedDocument [0..*] (RelatedDocument2) | |||||||||
componentOf [0..1] (Component1) | |||||||||
Subject | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:SBJ, default= "SBJ"} | |||||||||
subjectRole [1..1] (SubjectRole) | |||||||||
SubjectRole | |||||||||
classCode [1..1] (M) Role (CS) {CNE:x_DocumentSubject} | |||||||||
code [0..1] Role (CE) {CWE:RoleCode} | |||||||||
addr [0..*] Role (BAG<AD>) | |||||||||
telecom [0..*] Role (BAG<TEL>) | |||||||||
subject [0..1] (SubjectPerson) | |||||||||
SubjectPerson | |||||||||
classCode [1..1] (M) Entity (CS) {CNE:PSN, fixed value= "PSN"} | |||||||||
determinerCode [1..1] (M) Entity (CS) {CNE:INSTANCE, fixed value= "INSTANCE"} | |||||||||
name [0..*] Entity (BAG<PN>) | |||||||||
administrativeGenderCode [0..1] LivingSubject (CE) {CWE:AdministrativeGender} | |||||||||
birthTime [0..1] LivingSubject (TS) | |||||||||
RecordTarget | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:RCT, fixed value= "RCT"} | |||||||||
patient [1..1] (R_PatientUniversal) | |||||||||
ResponsibleParty | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:RESP, fixed value= "RESP"} | |||||||||
assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
Author1 | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:AUT, fixed value= "AUT"} | |||||||||
functionCode [0..1] Participation (CE) {CWE:ParticipationFunction} | |||||||||
time [1..1] Participation (TS) | |||||||||
assignedAuthor [1..1] (AssignedAuthor) | |||||||||
AssignedAuthor | |||||||||
classCode [1..1] (M) Role (CS) {CNE:ASSIGNED, default= "ASSIGNED"} | |||||||||
id [1..1] Role (II) | |||||||||
code [0..1] Role (CE) {CWE:RoleCode} | |||||||||
addr [0..*] Role (BAG<AD>) | |||||||||
telecom [0..*] Role (BAG<TEL>) | |||||||||
assignedAuthorChoice [0..1] (AuthorChoice) | |||||||||
representedOrganization [0..1] (E_OrganizationUniversal) | |||||||||
AuthorChoice | |||||||||
choice of Person | |||||||||
or AuthoringDevice | |||||||||
Person | |||||||||
classCode [1..1] (M) Entity (CS) {CNE:PSN, fixed value= "PSN"} | |||||||||
determinerCode [1..1] (M) Entity (CS) {CNE:INSTANCE, fixed value= "INSTANCE"} | |||||||||
name [0..*] Entity (BAG<PN>) | |||||||||
AuthoringDevice | |||||||||
classCode [1..1] (M) Entity (CS) {CNE:DEV, default= "DEV"} | |||||||||
determinerCode [1..1] (M) Entity (CS) {CNE:INSTANCE, fixed value= "INSTANCE"} | |||||||||
code [0..1] Entity (CE) {CWE:EntityCode} | |||||||||
softwareName [0..1] Device (SC) | |||||||||
DataEnterer | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:ENT, fixed value= "ENT"} | Transcriptionist | ||||||||
time [0..1] Participation (TS) | |||||||||
assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
Custodian | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:CST, fixed value= "CST"} | |||||||||
assignedCustodian [1..1] (AssignedCustodian) | |||||||||
AssignedCustodian | |||||||||
classCode [1..1] (M) Role (CS) {CNE:ASSIGNED, default= "ASSIGNED"} | |||||||||
representedOrganization [1..1] (E_OrganizationUniversal) | |||||||||
InformationRecipient | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:x_InformationRecipient} | |||||||||
intendedRecipient [1..1] (IntendedRecipient) | |||||||||
IntendedRecipient | |||||||||
classCode [1..1] (M) Role (CS) {CNE:x_InformationRecipientRole} | |||||||||
id [1..1] Role (II) | |||||||||
addr [0..1] Role (AD) | |||||||||
telecom [0..1] Role (TEL) | |||||||||
informationRecipient [0..1] (Person) | |||||||||
receivedOrganization [0..1] (E_OrganizationUniversal) | |||||||||
LegalAuthenticator | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:LA, fixed value= "LA"} | |||||||||
time [0..1] Participation (TS) | |||||||||
signatureCode [0..1] Participation (CE) {CNE:ParticipationSignature, default= "S"} | |||||||||
assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
Authenticator | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:AUTHEN, fixed value= "AUTHEN"} | |||||||||
time [0..1] Participation (TS) | |||||||||
signatureCode [0..1] Participation (CE) {CNE:ParticipationSignature, default= "S"} | |||||||||
assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
Participant | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:ParticipationType} | |||||||||
functionCode [0..1] Participation (CE) {CWE:ParticipationFunction} | |||||||||
time [0..1] Participation (IVL<TS>) | |||||||||
signatureCode [0..1] Participation (CE) {CNE:ParticipationSignature} | |||||||||
participatingEntity [1..1] (ParticipatingEntity) | |||||||||
ParticipatingEntity | |||||||||
classCode [1..1] (M) Role (CS) {CNE:RoleClassAssociative} | |||||||||
id [0..1] Role (II) | |||||||||
code [0..1] Role (CE) {CWE:RoleCode} | |||||||||
addr [0..1] Role (AD) | |||||||||
telecom [0..1] Role (TEL) | |||||||||
associatedPerson [0..1] (Person) | |||||||||
scopingOrganization [0..1] (E_OrganizationUniversal) | |||||||||
InFulfillmentOf | |||||||||
typeCode [1..1] (M) ActRelationship (CS) {CNE:FLFS, default= "FLFS"} | |||||||||
order [1..1] (Order) | |||||||||
Order | |||||||||
classCode [1..1] (M) Act (CS) {CNE:ACT, default= "ACT"} | |||||||||
moodCode [1..1] (M) Act (CS) {CNE:RQO, fixed value= "RQO"} | |||||||||
id [1..1] Act (II) | |||||||||
code [0..1] Act (CE) {CWE:ActCode} | |||||||||
DocumentationOf | |||||||||
typeCode [1..1] (M) ActRelationship (CS) {CNE:DOC, fixed value= "DOC"} | |||||||||
event [1..1] (Event) | |||||||||
Event | |||||||||
classCode [1..1] (M) Act (CS) {CNE:ACT, default= "ACT"} | |||||||||
moodCode [1..1] (M) Act (CS) {CNE:EVN, fixed value= "EVN"} | |||||||||
id [1..*] Act (SET<II>) | |||||||||
code [0..1] Act (CE) {CWE:ActCode} | |||||||||
RelatedDocument2 | |||||||||
typeCode [1..1] (M) ActRelationship (CS) {CNE:x_ActRelationshipDocument} | |||||||||
parentDocument [1..1] (ParentDocument) | |||||||||
ParentDocument | |||||||||
classCode [1..1] (M) Act (CS) {CNE:DOCCLIN, default= "DOCCLIN"} | |||||||||
moodCode [1..1] (M) Act (CS) {CNE:EVN, fixed value= "EVN"} | |||||||||
id [1..1] Act (II) | |||||||||
statusCode [0..1] Act (CS) {CNE:ActStatus} | |||||||||
setId [0..1] ContextStructure (II) | |||||||||
versionNumber [0..1] ContextStructure (INT) | |||||||||
Component1 | |||||||||
typeCode [1..1] (M) ActRelationship (CS) {CNE:COMP, default= "COMP"} | |||||||||
encounterEvent [1..1] (EncounterEvent) | |||||||||
EncounterEvent | |||||||||
classCode [1..1] (M) Act (CS) {CNE:ENC, fixed value= "ENC"} | |||||||||
moodCode [1..1] (M) Act (CS) {CNE:EVN, fixed value= "EVN"} | |||||||||
id [0..1] Act (II) | |||||||||
effectiveTime [1..1] Act (IVL<TS>) | |||||||||
encounterPerformer [0..*] (EncounterPerformer) | |||||||||
location [0..1] (Location) | |||||||||
EncounterPerformer | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:x_EncounterPerformerParticipation} | |||||||||
functionCode [0..1] Participation (CE) {CWE:ParticipationFunction} | |||||||||
time [0..1] Participation (IVL<TS>) | |||||||||
assignedPerson [1..1] (R_AssignedPersonUniversal) | |||||||||
Location | |||||||||
typeCode [1..1] (M) Participation (CS) {CNE:LOC, default= "LOC"} | |||||||||
healthCareFacility [1..1] (HealthCareFacility) | |||||||||
HealthCareFacility | |||||||||
classCode [1..1] (M) Role (CS) {CNE:SDLOC, default= "SDLOC"} | |||||||||
id [0..1] Role (II) | |||||||||
code [0..1] Role (CE) {CWE:ServiceDeliveryLocationRoleType} | |||||||||
location [0..1] (Place) | |||||||||
serviceProviderOrganization [0..1] (E_OrganizationUniversal) | |||||||||
Place | |||||||||
classCode [1..1] (M) Entity (CS) {CNE:PLC, default= "PLC"} | |||||||||
determinerCode [1..1] (M) Entity (CS) {CNE:INSTANCE, fixed value= "INSTANCE"} | |||||||||
name [0..1] Entity (EN) | |||||||||
addr [0..1] Place (AD) |